Fee Schedule Instructions
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Last Updated on: 9/3/2021 Fee Schedule Instructions Historical Behavioral Health Fee Schedules Fee Schedule Formats Format of CSV Fee Schedules Special Indicators on Fee Schedules Table Listing Fee Schedule Instructions Welcome to the Connecticut Medical Assistance Program enhanced fee schedule page. The fee schedules have been enhanced to provide different formats that can be easily viewed, downloaded and manipulated, and that have historical rate data. To reference provider bulletins with important fee schedule information, navigate to the Information page of this Web site by selecting Information > Publications and use the Publication Search feature to find provider bulletins for your provider type. Limited policy restriction information is only provided on the fee schedule. For a comprehensive set of policy information, please refer to Chapter 7 of the Provider Manual. To reference provider manuals, navigate to the Information page of this Web site by clicking on Information > Publications > Provider Manuals to find the provider manual for your provider type and click the “View Chapter 7” button. For enhanced pediatric and obstetrical services rate information, please review further down in the document the section titled Available Fee Schedules and the information provided under the “additional information column” for both the “Physician Office and Outpt Services” fee schedule. Historical Behavioral Health Fee Schedules This link contains Behavioral Health Partnership & Psychologist fee schedules produced prior to April 1, 2012. Fee Schedule Formats The most current fee schedules are now available in one of two formats as follows: o PDF –Portable Document Format - Fee schedules in this format (easily viewed and printed with free Adobe Acrobat Reader) contain footnoted information pertaining to some specific policies related to the procedure codes. This is a picture that cannot be sorted or modified in any way. This document can be saved to your PC. It is 1 important to note that this version is updated annually or when there are significant numbers of updates. o CSV – Comma Separated Values - A CSV file type can be opened in Microsoft Excel or other spreadsheet programs. This file type is available to providers in the event that providers would like to use the fee schedule data for any necessary calculations. This fee schedule format can be manipulated as any other Excel document, with available spreadsheet features such as sorting, filtering, and adding columns. Please note the following tips when using the CSV format. o To open a fee schedule in this format, simply click on the CSV link next to the appropriate fee schedule. On the Pop Up box that appears, press the Save button and Save in the folder of your choice and with the name of your choice. Go to folder where the file was saved and open the file. After it is open, save the file in the desired spreadsheet program by selecting the file type, such as Microsoft Excel. o Once the file is opened, providers will have to expand the column size of each of the columns. Providers may then perform any functions available in the selected spreadsheet program, such as sort, filter, print, and add columns. o If the provider is interested only in current rates and not historical rate data, use the filter function of the selected spreadsheet program to filter by the effective date. If the provider is interested in viewing current and historical rate information, do not apply a filter. o If the fee schedule is to be printed, it may be wise to choose landscape and add page numbers using the page number feature of the selected spreadsheet program. o If the CSV link doesn’t work for you, you may need to point to the link, right click and select Open to access the CSV format and/or on the pop-up blocker setting page there is a drop down with the Blocking level. If you have this set to "High" Then you need to override the popup blocker settings. You can investigate your settings in either of these ways: ▪ Tools | Pop-up blocker | Pop-up Blocker Settings | set the Blocking level to Medium ▪ Tools | Internet Options | Privacy tab | Click the Settings button in the pop- up blocker area | set the Blocking level to Medium Format of CSV Fee Schedules Each fee schedule contains the following data: • Heading – Indicates the name of the fee schedule. • Procedure Code – Indicates each procedure code that can be billed for that fee schedule. • Proc description – Includes a description of each procedure code. 2 • Mod1 – Includes any modifiers that can be billed with the procedure code. Modifiers will not be applicable to all fee schedules. • Mod1 Desc – Includes a description for the listed modifier. Beginning mid-May 2009, this field will be excluded on MEDS Fee Schedules. • Rate Type – The rate type is used to further define the type of rate for the provider fee schedule. Some fee schedules may only have one rate type, whereas others may have multiple rate types. The rate type gives DSS the ability to reimburse procedure codes at a different rate amount based on criteria such as client age or gender. • Max Fee – Indicates the maximum fee payable for that procedure code. • Effective Date – Indicates the effective date for that rate type and max fee amount. The fee schedule may contain multiple rate types, max fee amounts, and effective dates so that providers have historical rate data. • End Date – Indicates the end date for that rate type and max fee amount. • PA – Indicates whether or not prior authorization (PA) is required. If the column contains a value of Y then PA is ALWAYS required for a procedure code. If the PA indicator lists an “*” asterisk; that implies the PA applies to specific billing rule situations, not all. Ensure that you refer to Chapter 7 of the Provider Manual for situational PA requirements as this field shows codes that ALWAYS require PA. To reference provider manuals, navigate to the Information page of this Web site by clicking on Information > Publications > Provider Manuals to find the provider manual for your provider type and click the “View Chapter 7” button. • QTY – Applies only to MEDS fee schedules and indicates the quantity associated with the procedure code Special Indicators on Fee Schedules The Max Fee column lists the amount the procedure code will be reimbursed. Some fee schedules may contain special indicators in the Max Fee column. These indicators are: • MP – Indicates that a procedure code is manually priced. No rate will be listed. • PSR – Indicates that the rate for this procedure code is provider specific. No rate will be listed. • BLLACQ - Indicates to Bill Acquisition Cost. This applies to the Optician Fee Schedule (formerly vision) • %BILL – indicate that code pays a percentage of the claim billed amount. This applies to the Physician Surgical fee schedule. Please note you must do a find on the CSV format of “BILL” to locate the code. This value does not appear in the autofilter list if the CSV is filtered. MEDS Specific Values • Lst-15 – Indicates to be priced at the lesser of list minus 15% based on an appropriate published manufacturer's suggested retail price or Medicare Price if 3 available. Appropriate documentation regarding pricing must be available upon request. • Zero - Indicates that a procedure code is manually priced or requires PA. No rate will be listed. • CST+75 – Indicates for a hearing aid repair, the payment for repairs performed by the manufacturer or third party vendor are limited to the manufacturer or third party vendor's actual costs plus $75. Appropriate documentation regarding pricing must be available upon request. Table Listing The following tables provide fee schedules, rate types and other additional information: Table 1: The Enhanced Fee Schedule table, is a comprehensive listing of all fee schedules. The Rate Type column provides a 2 or 3 digit character value associated with the specific fee schedule that is used to generate the fee schedule. In a limited number of fee schedules, such as the physician fee schedule, the additional notes column contains specific instructions on how to use the Rate Type column. The Available Format column indicates whether the fee schedule is available in PDF or CSV. Table 2: The Rate Type table further defines the rate types used in each fee schedule. Table 3: Lists the Diagnosis Codes for Family Planning Services Table 3a: contains ICD-9-CM codes Table 3b: contains ICD-10-CM codes effective 10/1/2015. Table 4: The HUSKY Health Primary Care Rates lists the services eligible for enhanced payments under the HUSKY Health Primary Care for services furnished by certain primary care physicians. The rates will be effective 01/01/2015 to 12/31/2299. Please refer to bulletin PB-2014-75, PB-2015-44, PB 2017-44 and PB 2017-72 for further information. Table 5: Lists the services eligible for enhanced payments under ACA Section 1202 Increased Payments for Services Furnished by Certain Primary Care Physicians Table 6: Lists Physician Office and Outpatient fee schedule procedure codes payable for 08/527 FQHC billing non-FQHC services physician services - non-mental health. Table 7: Lists Physician Surgery fee schedule procedure codes payable for 08/527 FQHC billing non-FQHC services physician services - non-mental health. Table 8: Lists Physician Office and Outpatient fee schedule procedure codes payable for 08/527 FQHC billing non-FQHC services for mental health services. Table 9: Lists the Physician Office and Outpatient codes for OBS (Obstetrical) rate type ICD-10-CM codes effective 10/1/2015. 4 Table 10: Lists the ICD-10-CM Behavioral Health Diagnosis Codes effective 10/1/2015. Table 11: Lists the ICD-10-CM Pregnancy Diagnosis Codes not requiring PA for Lab Procedures 81220-81224 effective 10/1/2015.